Session III - Upper Extremity
Fri., 10/8/04 Upper Extremity, Paper #20, 3:38 pm
Minimally Invasive Palmar Reduction and Internal Fixation for Displaced Intraarticular Fractures of the Distal Radius with Locking Compression Plate (Lcp)
Purpose: The appropriate operative treatment of distal intraarticular radius fractures with significant displacement is controversial. Dorsally comminuted intraarticular compression fractures of the distal radius with displacement and positive instability criteria are commonly treated either by external fixation, K-wires, or open reduction and internal fixation (ORIF), mainly with dorsal plating and bone grafting. Most of those techniques show significant postoperative complications, with secondary loss of reduction, pin tract infection, tendon rupture, functional loss after immobilization, and complex regional pain syndrome type 1. We hypothesized that the innovative design of the locking compression plate (LCP), with angular stable screws, leads to sufficient volar stabilization of unstable distal radius fractures with dorsal comminution, preventing long-term loss of reduction despite early rehabilitation without a cast.
Methods: Eighty-one patients (age, 57.4 ± 4.7 years) with a comminuted displaced distal radius fracture were enrolled. Open reduction and internal fixation was performed through a volar approach with use of the LCP with angular stable screws. Bone grafting was not performed in any patient. Sixty-nine patients were treated functionally without a cast, and 12 patients were treated with a cast during the first 2 to 4 postoperative weeks. The fractures were assessed radiographically by measurement of palmar tilt, dorsal shift, and ulnar variance. Evaluation in hospital was performed preoperatively and 1 to 3 days postoperatively. Follow-up evaluation was performed 6 and 12 months postoperatively. The Gartland and Werley score as well as the DASH score were evaluated.
Results: The mean follow-up time was 15.4 ± 4.2 months.
The AO classification included: A2, 12; A3, 5; B1, 2; C1, 17; C2, 33; and
C3, 12. All fractures healed with highly satisfactory radiographic and functional
results:
palmar tilt angle preoperatively, 14.9° ± 19.6°; 1 to 3 days
postoperatively 4.8° ± 10.4°. Preoperative dorsal shift,
14.3 ± 4.6 mm; 1 to 3 days postoperative dorsal shift, 10.9 ±
2.8 mm. Preoperative ulnar variance, 1.8 ± 3.4 mm; 1 to 3 days postoperative
ulnar variance, 0.7 ± 1.9 mm. There were no significant differences
in palmar tilt angle, dorsal shift, and ulnar variance between the immediate
postoperative evaluation and the 6-month follow-up. The overall outcome
according to the Gartland and Werley score showed 49% excellent, 41% good,
9% fair, and 1% poor results. The DASH Score 12 months after surgery was
15.2 ± 6.9 points. The following complications were observed: infection,
2; complex regional pain syndrome type 1, 1; rupture of flexor pollicis
longus tendon, 1.
Conclusions: This technique offers several advantages, even in elderly patients with osteopenic bone, including rigid plate fixation, allowing for early functional treatment without a cast. Bone grafting, with its significant morbidity, is not necessary, even in distal radius fractures with dorsal comminution. There were a low number of injuries to adjacent structures (tendon, nerve) and a low rate of complex regional pain syndrome type 1.